Identifying Clinical Practice Patterns of Integrated Primary Care Psychology Interns and Postdocs: Implications for Training

Transcription

1 Identifying Clinical Practice Patterns of Integrated Primary Care Psychology Interns and Postdocs: Implications for Training Christina L. Vair, PhD 1 Gregory P. Beehler, PhD, MA 1, 2 Jennifer S. Funderburk, PhD 1, 3 1 VA Center for Integrated Healthcare 2 University at Buffalo, The State University of New York 3 Syracuse University

2 Disclosures Study conducted with support from VA Center for Integrated Healthcare Department of Veterans Affairs Office of Academic Affiliations Advanced Fellowship Program in Mental Illness Research and Treatment (MIRECC) VA Western New York Healthcare System at Buffalo The Collaborative Family Healthcare Association Research Fellowship (2013) No conflicts of interest, financial or otherwise, to disclose. The views expressed in this presentation are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. 2

3 Presentation Overview Background The Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ) Study Goals Examine practice patterns of advanced psychology trainees using the PPAQ Relationships between PPAQ domain scores and training experiences Method Findings Implications Facilitating evidence-based training Limitations and Future Directions 3

4 Learning Objectives Describe practice patterns of advanced psychology trainees on the Primary Care Behavioral Health Provider Adherence Questionnaire, a validated measure of behavioral health provider fidelity. Identify advanced psychology trainee clinical practices and describe implications of these findings in addressing specific evidence-based training needs for providers in Primary Care (PC) Behavioral Health. 4

5 Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ) The PPAQ is a evidence-based, empirically validated self-report measure that examines fidelity to the Primary Care Behavioral Health (PCBH) model by assessing essential and prohibited provider behaviors (Beehler, Funderburk, Possemato, & Vair, 2013). Questionnaire items classified based on relevance for practice in PCBH Essential (consistent with the integrated care model; required for good practice) Prohibited (inconsistent with the integrated care model; should be avoided) 48 items representing provider behavior across four practice domains Clinical Scope and Interventions Practice and Session Management Referral Management and Care Continuity Consultation, Collaboration, and Interprofessional Communication 5

6 PPAQ, cont. Validation study conducted to determine reliability and validity of measure 173 VA Primary Care-Mental Health Integration (PC-MHI) providers completed PPAQ as part of validation study (Beehler, Funderburk, Possemato, & Dollar, 2013) Latent class analysis utilized to identify clusters of providers based on responses to PPAQ items (Beehler, Funderburk, King, Wade, & Possemato, 2015) Can the PPAQ be used to identify potential gaps in trainee translation of evidencebased practices? Relatively few doctoral-level training programs with emphasis in PC psychology; modest growth in availability of pre-doc internships and post-doc fellowships. Newly trained psychology interns and fellows represent substantial portion of the future workforce. The number of optimally trained psychologists remains sparse (Beacham et al., 2012; Blount & Miller, 2009). 6

7 Study Goal Examine practice patterns of advanced psychology trainees on the PPAQ How do trainees scores compare to seasoned providers responses from PPAQ validation study? Essential (PPAQ-E) and Prohibited (PPAQ-P) subscales Four practice domains Are there differences in PPAQ domain scores based on trainee practice environment? Clinic model Coordinated Care, Collaborative Care, Integrated Care, Current practice setting VA versus other settings How do trainees prior experiences relate to PPAQ domain scores? Total number of months in current PC role Items representing total training experiences, prior intervention training, access to resources, frequency of use of evidence-based practices (EBPs) in PC, and comfort in use of EBPs 7

8 Types of Primary Care Settings Collaborative Care Coordinated Care Integrated Care Definition primary care and psychology providers/trainees deliver care in the SAME practice setting primary care and psychology providers/trainees practice SEPARATELY within their respective systems and exchange information as needed primary care and mental health providers/trainees work as a tightly integrated, on-site TEAM with unified care plans 8

9 Analyses PPAQ-P and PPAQ-E: Comparison of current sample vs. validation sample PPAQ Domain scores: ANOVA of PC clinic model by domain mean score(s) T test of setting by domain score(s) Correlational analyses of trainee PPAQ domain scores: number of months in PC role summations of past training experiences, frequency of and comfort in utilizing evidencebased practices 9

10 Demographics National web-based survey of pre-doctoral psychology interns and postdoctoral fellows (N = 100) with prior training experiences in PC Pre-doc intern: 50.9%, Post-doc fellows: 48.2% 74 Female, 24 Male, 2 Transgender Age: M = 31.3 (SD = 4.3, Range: 25 to 56) 90% White, 4.5% Black, 4.5% Asian,.9% American Indian or Alaska Native Graduate training programs Clinical Psychology: 85.7%, Counseling Psychology: 8.0%, Health Psychology: 5.0% Current training sites VA: 73.2% Non-VA: Outpatient medical clinic: 12.5%, FQHC: 8.9%, Other: 5.4% Number of months in current PC role: M = 9.29 (SD = 6.89, Range: 2 to 34) Theoretical orientation Cognitive Behavioral: 70.5%, Integrative: 11.6%, Behavioral: 5.4%, Psychodynamic/Psychoanalytic: 3.6%, Other: 8.9% Primary care clinic model Integrated Care: 40.2%, Collaborative Care: 35.7%, Coordinated Care: 15.2% 10

11 Comparison to PPAQ Validation Study Trainees had higher mean total score on PPAQ-E subscale, lower mean score on PPAQ-P subscale compared to validation study sample Trainees: PPAQ-E : M = 152 (SD = 18 ) PPAQ-P: M = 19 (SD = 5) Validation study sample: PPAQ-E : M = 144 (SD = 19) PPAQ-P: M = 21 (SD = 5) Mean scores suggest trainees demonstrating better overall fidelity to PCBH model Significant difference in PPAQ-E scores (F [3.96] = 3.72, p =.01) based on access to resources, consistent with validation study No statistically significant relationship between CBT theoretical orientation and PPAQ-E subscale scores, unlike finding from validation study 11

12 Comparison to Validation Study, cont. PPAQ Practice Domain Full Sample Low Performing Subsample High Performing Subsample Trainees Clinical Scope & Intervention Practice & Session Mgmt Referral Mgmt & Care Continuity Consultation, Collaboration & Interprofessional Communication On four practice domains of PPAQ (Beehler, Funderburk, King, Wade, & Possemato, 2015) Trainees had higher mean scores than full validation study sample Trainees reported scores similar to the high performing subgroup found in latent class analysis 12

13 PPAQ Domains by PC Model (1) Integrated Care (2) Collaborative Care (3) Coordinated Care M SD M SD M SD Clinical Scope & Interventions Practice & Session Management Referral Management & Care Continuity Consultation, Collaboration, & Interprofessional Communication Post hoc comparisons: 1 > 2 > Trainee scores on PPAQ domains suggest increased level of fidelity within each domain as level of integration within clinic setting increased 13

14 Consultation, Collaboration Referral Mgmt, Care Continuity Practice and Session Management Clinical Scope & Intervention Integrated Care Collaborative Care Coordinated Care 14

15 Correlations Between Past Training and PPAQ Domains Clinical Scope & Interventions Practice & Session Management Referral Management & Care Continuity Consultation, Collaboration, & Interprofessional Communication Prior PC Training Prior EBP Training Frequency of EBP Use Comfort in EBP Use.17.27**.27**.30**.23*.38**.32**.46**.30.29**.52**.47**.26.38**.34**.46** * Correlation significant at p =.05; ** Correlation significant at p =.01 15

16 Results, cont. Subsequent analyses on PPAQ domains demonstrated No significant differences on any of the domain mean scores between Interns and post-docs Trainees identifying as having a cognitive-behavioral theoretical orientation versus all other theoretical orientations Trainees in VA versus non-va settings Domain mean scores not significantly correlated with number of months in integrated care role Negative, non-significant correlation between number of months and mean score for Clinical Score and Interventions (r = -.03), Practice and Session Management (r = -.01) 16

17 Summary and Implications The PPAQ is the first reliable, validated measure of provider fidelity for PCBH model Present study demonstrates possible utility of measure with trainees Trainees with experience in integrated care (as opposed to coordinated or collaborative care) scored highest across domains, scored similarly to high performing sample from validation study Findings indicate that psychologists trained in settings other than integrated care (i.e., coordinated or collaborative care) may have greater need for additional training to maximize fidelity to PC-BH model, utilization of evidence based practices Findings suggest need for training programs to emphasize evidence-based training: skills for consultation, collaboration & interprofessional communication use of and comfort with relevant EBPs 17

18 Limitations and Future Directions Limitations Relatively small sample size Representativeness of sample Bulk of participants currently practicing in VA settings Majority reported PC clinic model as integrated care Possible social desirability bias in responses PPAQ designed to measure PCBH model, specifically Validation sample included only VA PC-MHI providers Future directions Using PPAQ in different types of training programs to help further understanding of gaps in evidence-based training for behavioral health providers Using PPAQ to help further refine, define program descriptions, consistency in use of terminology Combine PPAQ with other program development activities (e.g., facilitation and coaching) to monitor and support trainees development Linking trainee and other provider clinical practices to patient outcomes PPAQ Tool Kit (Lilenthal & Beehler, 2016) 18

19 References Beacham, A. O., Kinman, C., Harris, J. G., & Masters, K. S. (2012). The patient-centered medical home: Unprecedented workforce growth potential for professional psychology. Professional Psychology: Research and Practice, 43(1), Beehler, G. P., Funderburk, J. S., Possemato, K., & Vair, C. (2013). Developing a measure of provider adherence to improve the implementation of behavioral health services in primary care: A Delphi study. Implementation Science, 8, 19. Beehler, G. P., Funderburk, J. S., Possemato, K., & Dollar, K.M. (2013). Psychometric assessment of the Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ). Translational Behavioral Medicine, 3, Beehler, G. P., Funderburk, J. S., King, P. R., Wade, M., & Possemato, K. (2015). Using the Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ) to identify practice patterns. Translational Behavioral Medicine, 5(4), Blount, F. A., & Miller, B. F. (2009). Addressing the workforce crisis in integrated primary care. Journal of Clinical Psychology in Medical Settings, 16(1), Lilienthal, K., & Beehler, G. P. (2016, March/April). Primary care behavioral health provider perceptions of the PPAQ Toolkit for quality improvement. Poster accepted for presentation at the 37th Annual Meeting and Scientific Sessions of the Society of Behavioral Medicine, Washington, DC. 19

20 Questions?